Types of treatment taken at home
Few participants reported taking immediate steps to treat their fever. Most waited a few days before seeking treatment outside the home, either because they were waiting for symptoms to worsen and/or to ensure the fever was not the result of a simple cold or flu. They also waited because they were in the forest, far away from health centres or outlets where they could purchase medicines.
Respondents also reported that medicines are expensive and they did not have the money to treat their fevers. Thus, a common alternative is to treat the fever at home, using traditional remedies. Many believe the symptoms can be treated successfully at home, an impression that is also rooted in their perception of the seriousness of the illness.
Moderator: When you have a hot temperature, where do you go for treatment?
Respondent 1: First, we treat it at home by ourselves. We use different medicines to make us feel better, and which help reduce the fever. The elders say to use a kind of roof thatching plant, corn and a kind of aquatic herb that is used as a spice and which keeps for a year. We boil the core of the corn and use this to treat the fever.
Respondent 2: But if the fever is not any better after two or three days, we may go to a hospital or a shop that sells medicines.
Respondent 3: But if it is serious from the start, we will go to the hospital right away.
FGD, Pursat Province
Home treatment includes traditional medicines, primarily used to delay, alleviate and/or cure symptoms before seeking modern alternatives. Most reported drinking boiled tree roots (e.g. the roots of the lemon tree with alcohol or kapok leaves) or taking warm sponge baths with fragments of ginger, or with guava leaf and the leaf of a small, sour fruit. They also use other natural remedies, as described by this forest worker:
Respondent: If we are in the forest, we have nothing with us. So, we just have trees in the forest such as “Ampil Brok Phler” and “Merm Krovanh Chruk”. We just eat them when we do not have medicines. Moreover, there are “Cheung Kras” grass, and also coconut stumps which we cut to eat. These are temporary medicines in the forest until we arrive home. When we have a serious fever, we can cut the coconut core into two pieces, tie it with black thread, insert a nail, and then boil them together to drink until we get medicine. … The [traditional medicines] can help around 30% or 40%. They can protect us from running a high temperature. But these won’t be effective for long, so, three or four days later, we will start shivering again. However, this mixture helps us to be able to ride our ox cart home
IDI, 32 year-old, Male Forest Worker, Pursat Province
While treatment at home is commonplace among respondents, they generally sought help outside the home from a qualified provider of health care if the home treatment strategies were perceived as ineffective or failing, or if symptoms worsened. This source outside the home was most often the nearest provider of modern medicines. Sometimes respondents resorted to using modern medicines that they had left over from a previous episode of illness, even if these medicines were not anti-malarials.
Reasons for taking cocktails
While many respondents rely on traditional medicines as a primary treatment, the majority of participants eventually receive some form of modern medication for their malaria symptoms. A few participants mentioned brand names without prompting from the interviewer or FGD facilitator, typically the ACT Malarine (private sector) or A + M (public sector). However, most respondents did not name the medications they received. The most common point shared by all respondents about modern medications focused on cocktails. When they sought modern treatment, they often received medicines without formal packaging, presented as cocktails. Therefore, this section focuses on the study results surrounding the perceptions of cocktail medicines, rather than the perceptions of pre-packaged medicines.
Respondents reported the cocktail medicines are presented in different forms. Sometimes, the cocktails consist of complete blister packs that have simply been removed from pre-packaged medicine boxes. In other cases, providers have cut up the blister packs or removed the pills from the blisters or tins altogether, placing these individual pills in the mixture. The providers prepare all of these formulations in small plastic bags. Instructions for taking these cocktail medicines direct participants to take them multiple times a day over the course of several days, typically using the colour of the pill in the cocktail (e.g. blue, white, yellow or red) to denote which medicines to take at specific times. Sometimes the instructions describe a sign or picture imprinted on the pill(s). Some respondents reported linking the colour of the pill with the perceived curative agent. For example, they described the red pills as the pills for energy, while the light blue pills were “new” treatments for malaria.
Moderator: What sort of medicine were you offered?
Respondent 1: I got pills in a plastic bag. The provider removed different pills from a blister pack and some from a big container, and put them into the plastic bag.
Moderator: The provider removed them from the blister pack?
Respondent 1: Yes, she did.
Moderator: What about others here? What medicine did you get?
Respondent 4: I don’t know. The health provider just prepared a bag for me to take twice per day, morning and afternoon. I didn’t understand [anything] about those medicines. I could not recognize them, but I knew they related to malaria and typhoid. The health providers told me. They gave me the tablets after I got serum.
Moderator: Did the medicine come with its original package or cover?
Respondent 4: Some came with its original packaging, some didn’t. It came in a small plastic bag.
FGD, Pursat Province
Among study participants, the use of cocktails is widespread and is viewed as a “normal” medicine given by providers. Given the frequency with which respondents mentioned receiving cocktails, this type of treatment is deemed a common, standard treatment for all symptoms. Respondents did not question the efficacy of the cocktail treatments, regarding them as a “normal” and “common” type of treatment for malaria from health providers. They cited trust in the efficacy of these treatments. In addition, respondents perceive the inclusion of multiple types of pills in cocktail packages as more effective and less expensive than a pre-packaged medicine. Many described the need to not only cure malaria, but also to reduce fever and headaches; thus, a combination of pills, targeting multiple symptoms, is deemed more effective and more affordable than purchasing multiple pre-packaged medicines. Respondents also generally cited trust in their providers and believed that the provider would only give them an effective medicine:
Interviewer: Do you think these [cocktail] treatments are effective?
Respondent: Yes, they are good treatments because I always get better after treating [my illness with them]. And I believe in the medicines because they are given to me by health providers. They save us. It is the provider’s job to save us.
Interviewer: How much do you believe in these treatments?
Respondent: I believe almost 100%.
IDI, 29 year-old, Male Forest Worker, Kratie Province
Many respondents also discussed how the cocktails are often saved for later illnesses, or for when they return to the forest. They also reported stopping the medicine regimen prematurely because they felt better, or they needed the medicines for other family members or their own future illnesses, as illustrated by this exchange:
Respondent 2: He [the provider] told me to take it [the medicine] regularly and on time, and that I have to finish it even if I am better. And I did follow his advice.
Moderator: What about others?
Respondent 3: No, I will finish all of it [the medicine].
Respondent 4: I keep one in reserve in case we are sick next time.
Respondent 5: For me, they prepared four to six bags for me. And after I finished four bags, my kid became sick. I knew he had malaria as his toes were cold and he had a headache… and he told me he felt numb. His face was also numb. So I gave him some [medicine]. For older people, we need to take only one tablet, so I cut it into two parts [for my son]. I just give him half a tablet. After I gave him the medicine, he got better.
FGD, Pursat Province
Reasons for diagnostic testing
The data suggest that many respondents are not aware they need a diagnostic blood test to confirm their fever as malaria. Many also believe they do not need to do a test because they are able to self-diagnose malaria. Since many participants claimed they “knew” it was malaria because the symptoms they had experienced were the same as those from previous bouts of the illness, they felt that the additional cost imposed by testing seemed fruitless. Sometimes this perception was linked to previous experiences with diagnostic testing; those who had had prior experience with tests that confirmed fever as malaria now felt in a better position to recognize when fever episodes were malaria. Others reported that providers did not mention the need for a test. Some participants also noted that they did not know where to get tested.
Respondent 3: For me, I just went to the shop and got the medicines. The provider did not tell me to take a test or anything. He gave me medicines and told me to take them to cure my fever. So I did. I didn’t know anything about a test.
Respondent 2: I just got the medicine, too, from the place near my house. It was given to me for curing my malaria. I don’t even know where I should find such a test for malaria.
Respondent 5: Going to have our blood tested once is enough for us. Next time if we have the same symptoms, we do not have go get diagnosed again. Instead, we can just buy medicine from the drugstore. We know when it is really malaria.
Respondent 8: From my experience, I am used to having malaria. I observe my son and myself [when we get sick]. It starts first with yellow eyes. The eyes start being yellow after we return from the forest. When I open his eyes, it looks like there is not any red blood inside them. It’s all a big fever virus. Some called it like the souls of our ancestors knock us out. It starts with feeling cold and hot temperatures again and again. No chills, but after three days, it becomes a serious fever, and then you become unconscious. From this, I know it is malaria.
FGD, Kratie Province
For respondents who mentioned seeking treatment from public or private facilities or clinics, many did not question the need for a diagnostic test because they trusted their provider to give them the appropriate treatment. This finding contrasted with responses from those who obtained treatment from less formal outlets including village shops or markets; these respondents did not comment on the quality of the provider. Participants perceive public and private health care providers as knowledgeable and experienced, as well as able to ascertain what type[s] of medicine is needed based on their symptoms. Providers are viewed as being a source of authority in treatment and diagnosis. Several respondents reported they would accept any decision handed down by the provider. Often they were not challenged by the provider to have a test, as illustrated by the following discussion:
Respondent: When I got to the health facility, I told the provider to give me anti-malarial medicine. Also, the provider did not request or provide blood testing for me, but only gave me a cocktail.
Interviewer: So what did you tell the provider?
Respondent: When I arrived, I asked him if he could please give me anti-malarial medicine “for three times” and he did that for me. In fact, he also has test equipment [but he didn’t use it on me].
Interviewer: Why did you ask him to give you anti-malarial medicine?
Respondent: Because I think my disease is really malaria. So I just tell him to give me anti-malarials, which he did for me.
Interviewer: So, he did not ask you anything?
Respondent: He did ask me a few questions, something like “How did you get malaria?”
IDI, 22 year-old Female, Kratie Province
In contrast, those who received diagnostic testing noted that blood tests are also seen as part of the treatment plan, as well as something that is prescribed by providers. The data suggest that receiving a test is often dependent on where people purchased or obtained medicines. Typically, respondents mentioned receiving a test when they sought treatment from a public health facility or a private hospital. They also talked about the role of the provider in this process, citing that receiving a test is up to the health provider, either public or private, as illustrated by the quote below:
Respondent 5. When I arrived, the doctor said that I have to have a blood test, in order to make it easier to prescribe the proper treatment. If we do not have a blood diagnosis, we cannot know what disease it is, and so we cannot provide proper treatment. After the blood test, I was informed I have three positive signs of malaria and I was given A + M.
Respondent 7: First, my feet were cold and I felt my neck was cold too. So, then I warmed myself by the fire. After doing this, I was still cold. Then, I went to sleep without taking any medicine. I started out really cold until I covered myself with a blanket, but I was still cold. So, I took two tablets of paracetamol, which [made me feel] better, although I was sweaty for a while. Then the chills started again. After that, I was brought to the hospital.
Moderator: How many days were you sick before you went to the hospital?
Respondent 7: Three days, then I went to the hospital. As I did not recover, I went to the hospital for a blood test. They asked me where I had been. And I said that I had been in the highland area. Then they asked me to have a blood test. So, I took it.
FGD, Kratie Province
In other instances, participants said they specifically sought a diagnostic test in order to understand their illness, or in order to correctly diagnose the illness and find the appropriate treatment. In these cases, although they had familiarity with some malaria symptoms, they recognized they could not identify the illness on their own and, therefore, needed a blood test to confirm the cause of the fever. Others reported taking medicine first without being tested. When the symptoms did not improve, they decided testing was necessary to find the “right” treatment. In addition to aiding the identification of the correct treatment, confirmation of disease also prevented the risky behaviour of taking an anti-malarial when it was not needed. Doing so was seen as “dangerous”. Participants explained the effects of unnecessary anti-malarial treatments as “harming the blood vessels”, “making blood thick”, “weakening the blood” or “shattering the blood bullet”.
Respondent: Because I felt uneasy inside my body, I even took traditional medicine as well as the cocktail which I had bought nearby. I did not recover. I just spent money on the medicine without getting good results. That was why I needed the blood test.
Interviewer: When you got the blood test, did you request the provider to do it for you or did you just go there to see what the provider would recommend?”
Respondent: I asked him to do it because I felt strange in my body. I always had chills and fever and could not get better by taking the medicine. And I wanted to know what illness it was, and why I did not get better even after taking the medicine. So, I asked him to do the blood test to identify the disease.
Interviewer: Before you did the blood test, what did you take?
Respondent: Beforehand I just took medicine like paracetamol and stuff like that for when you have a fever, and also the thing called Tetra [tetracycline].
Interviewer: Oh, so you didn’t have anti-malarial medicine?
Respondent: No, that time I did not know I had caught malaria until I did the blood test. If I had known that I had caught malaria, I could have chosen the right medicine
IDI, 34 year-old, Male Forest Worker, Kratie Province
Respondents also reported taking a blood test before going to work in the forest, particularly if they were experiencing malaria symptoms already. They wanted to ensure the malaria was cured before they travelled long distances where they would be required to work and sleep in areas far from any health facilities. They also reported taking cocktails with them in order to have medicine on hand in the forest in case they experienced new symptoms, as this participant demonstrates:
Interviewer: Uncle, did you do the blood test?
Respondent: I did it before going to the forest.
Interviewer: How many days did you do the blood test before you went to the forest?
Respondent: Three days before I went to the forest. However, before I went to the forest, I already had had fever one or two times. That is why I did the blood test. I thought I could not take cocktails if I go to the forest again and I do not know what disease I catch. So I needed to do the blood test to see what illness I have. Then, I could buy cocktails to take to the forest.
IDI, 45 year-old, Male Forest Worker, Pursat Province
A number of respondents talked about obtaining multiple blood tests. They reported that providers could not recognize the results or needed to double-check the results at times. Many participants also reported confusion in ascertaining what the results of their tests were. Sometimes, they were unclear if they had tested positive for malaria or other illnesses, namely dengue fever or typhoid. In some cases, providers had given respondents anti-malarials even though their test results were negative. Others reported getting mixed results from the test:
Respondent 7: First, I had a blood test. The results showed that I was positive for malaria. I recovered after I took medicine for malaria. Then I got the chills again at 8 o’clock. I told my mother that I was not recovered yet. So, my mother took me to have a blood test again. The results showed I was positive for typhoid, not malaria.
FGD, Pursat Province